The PANY Bulletin

Psychoanalytic Association of New York
Volume 39, Number 3 Fall 2001

Aggression in a Latency Age Girl:
A Clinical Presentation
by Ruth S. Fischer, M.D.
(February 12, 2001)

Discussant: Leon Hoffman, M.D.
Reporters: Herbert H. Stein, M.D.
Ellen Abrams, M.S.W.

Dr. Fischer opened her presentation with an outline of her goals:

"Body sensations influence the way in which the child experiences and organizes her world. Psychosexual development mobilizes conflicts, defenses and adaptive maneuvers and character structure is established. This has been well explicated for oral, anal and phallic sensations. It has been much less well defined for the girl's genital sensations. My interest in tonight's presentation is to focus on the early genital phase and to consider the girl's psychic development under the impact of aggression as it molds and is molded by her genital sensations.

"I am presenting three ideas for consideration. 1. In the early genital stage of development, there is enhanced awareness of genital sensations and of anatomical difference that lead to an intra-psychic reorganization. 2. This will be interfered with when pre-oedipal ambivalence and separation-individuation have not been adequately resolved. 3. Imaginative play is a developmental milestone indicating the establishment of this psychic reorganization. It expresses a forward movement in the development of femininity. The girl now utilizes this adaptive maneuver in mastering her body and her environment. She also utilizes it in aggressive expression.

"Aggression here is defined as a striving toward with both a constructive and a destructive component. It encompasses anger, hostility, competition, envy, mastery, self-assertion, self-definition, sense of agency and a sense of power."

Dr. Fischer's presentation centered around the case of a girl who came to treatment at 6 years old suffering with temper tantrums, nightmares and separation anxiety. She had increasing difficulty leaving for school and entered her parents' room at night when she couldn't sleep. This was occurring in a atmosphere of "increasing marital discord."

"Martha" entered treatment with a grown up facade, sitting up and talking about her tantrums and insomnia. When she quickly could not continue to maintain that facade, she turned to arranging things in the office. Even as she began to relax, she had to maintain autonomy and control. For some time, she brought her own food and playthings to the office. She had difficulty using her imagination, resorting instead to action. This worked well, but when it was blocked, she exploded into screaming and yelling.

Although Martha attempted to control the sessions, there was also evidence that she became anxious if she felt too much in control. "Dependency was dangerous, but freedom of expression also felt dangerous. We focused on this anxiety and considered possible sources. ... It was important that she feel understood and respected. It was also important that she feel that she did not run the show -- at least not all of the time and not beyond her limit. Feeling that I would maintain control without being controlling was essential although at the same time it was constantly tested and resisted." For instance, Martha at first screamed when Dr. Fischer attempted to point out that she hid her cards while playing with them. As Dr. Fischer persisted without being overwhelmed or reactive to Martha's outbursts, Martha gradually calmed down and became more involved as a patient. "I now included in my repertoire her pushing me away after there had been some greater connection between us."

Martha became more involved with interactive play--playing catch with a pillow, making little messes in the office and then cleaning them up while keeping an eye on Dr. Fischer to see her reactions. There was a prolonged period of playing catch, in which both the ball and the conversation went back and forth.

Finally, she felt trusting enough to begin to express her worries, always adding a reassurance. "She was scared about starting school in the fall, but 'Everyone is. I'll be fine." She fell playing soccer. 'It was nothing.' One of the girls didn't want to play with her. 'I don't care.' Her conflict was clear. Her worry about her worries was profound. ... As we pursued this, she began to understand her concerns about her mother's vulnerability."

The conflict became more clearly centerd around a fear of being pulled into her mother and/or Dr. Fischer by her neediness. She began to turn more to her father for support, beginning to call him from the sessions. "In each instance thoughts of father arose as the pull to a relationship with me became stronger. The enhanced connection with me that allowed her to express more of her feelings also brought fears to the surface and thoughts about her father that somehow diminished her anxiety. The nature of the fears was both object related, a fear of loss of self or other, and drive related, as became clearer in subsequent sessions."

She next began to talk about her masculine and feminine sides through the vehicle of a book about a pair of twins both alike and different. "One liked dancing, the other soccer. One was smart, clean, orderly and finished her work on time. The other dirtied her clothes, did poorly in school, and didn't do her homework." She began to get confused about which was which, gradually opening the discussion about her own identity. She loved sports and used that interest "to bolster her masculine identification and to deny her sense of vulnerability. ... She had no interest in 'girly' things. ... 'Girly clearly meant vulnerable.'"

Dr. Fischer saw a connection between Martha's anger and her fear of femininity. She became more comfortable expressing her anger. "As her anger diminished, she became more identified with her mother, seemed less worried about her mother and was more able to compete with her. ... Anger, in particular, stressed her femininity. It was what evoked a turning away from anything 'girly'. This became clear as time after time we noted phallic activity appearing when she experienced great anger and vulnerability. As she became more comfortable with her anger, she became less stridently masculine in appearance and interests and less stridently controlled and independent."

With improvement, Martha became more imaginative. She began to explore more clearly oedipal concerns through her worries about jealousy and rivalry with here sister and mother. As she entered pubescence, her initial symptoms were under control.

Dr. Fischer discussed Martha's "feminine development." She said that Martha's aggression had a "driven phallic quality" that "left no room for femininity. The phallic quality that I refer to is that of a thrusting oneself into things, the preoccupation with the body or its substitutes in motion through space. This is most frequently noted in play with cars, trains, planes, superheroes and spacecraft. All of which is traditionally related to the sensations that the boy experiences in his penis. This is the psychic organization of the phallic stage of development.

"The girl's genital sensations lead to a spinning or dancing motion. For her, the psychic result is a turn inward promoting the use of symbols, the use of the imagination, drawing and story telling and the development of inter-personal skills, all of which were absent or inhibited in Martha. Interest turns to babies, to fantasies of mothering and producing, to seeds being planted and things growing in the ground. Enclosures are explored: mazes, holes, caves and tunnels. At times, attention turns to earthquakes and volcanoes, to the heat and excitement of forces erupting from deep within."

Dr. Fischer addressed the issue of Martha's inhibited femininity. She raised the question of a cultural determinant, a new attitude towards girls that blurs the difference in how boys and girls are handled and envisioned by parents and others. Her answer was, "Maybe, but pressing body sensations continue to deliver a message of their own. It is in this realm that Martha was having a problem. ... Rage seemed to be the underlying source of this need for action." As Martha's hostility diminished, her ability to relate, her imaginativeness and her femininity became more evident. Her anger also interfered with separation-individuation. She could not be comfortable with autonomy or dependence, to be close to her mother or Dr. Fischer, because of her ambivialence. "She could not deal with the oedipal competition under the pressure of so much anger. Here alone was reason to turn from her femininity."

Dr. Fischer understood Martha's phallic aggression as defensive, bolstering her distance from her mother and her femininity and allowing her to be close to her father without confronting oedipal competition. It also allowed her expression through action "while avoiding the dangers associated with connection and inside things." As her rage was defused in treatment through "relationship and insight," development resumed. "In expressing and exploring her anger, her rage diminished in intensity, her relationships deepened, her imagination soared and her femininity blossomed." She did not relinquish her interest in "baseball and soccer", but added other interests. Martha had used masculinity to maintain control. It had helped her distance herself from her mother, who was seen as vulnerable in the face of a possible disruption in her marriage and helped her control her own intense ambivalence.

Dr. Fischer saw Martha's case as "a problem in female development: the girl who is entering latency and is unable to turn inward and use her imagination."

"The turn inward and the use of imagination are noted to develop in the early genital stage. The girl turns to imaginative play in her efforts at mastery and integration. It becomes a new and significant ego function. Here we see a striking gender difference. ... So much of the girl's developmental experience works to foster this turn inward and toward others. The stage has been set in gendered ways in which parents interact with their children, in the girl's earlier sense of separateness making connection more imperative, rapprochement stickier and ambivalence more intense. Aggression, i.e. triadic competition and self-assertion are therefore often more problematic.

"Culturally, we are allowing as well as promoting more action related activities for girls. We are not requiring them to be 'girly' all of the time. But we contiue to see little girls wanting to put on dresses and play with dolls, wanting to act like mommy and to be seductive with daddy. We also see them playing ball, climbing monkey bars and trying to run the fastest. And we see latency-aged girls turning more inward, drawing pictures and making up stories. Character is molded by genital sensations as well as by environmental determinants."

Leon Hoffman, M.D.

Dr. Hoffman raised some questions about Dr. Fischer's conclusions. "As psychoanalysts we study the individual ... From psychoanalytic data we can make certain inferences about unconscious mental activity and particularly we tend to conclude with causative propositions. I would like, at the outset, to state that conclusions from psychoanalytic data about causation may be fraught with danger. For example, Dr. Fischer states ... that 'in the early genital stage of development, there is an enhanced awareness of genital sensations and of anatomical difference that lead to an intra-psychic reorganization.' That statement sounds as if one can conclude that awareness of the anatomy causes the intra-psychic reorganization. It would be more accurate to say that there is a correlation between these two conditions (awareness and reorganization). A priori, we do not know whether the awareness leads to reorganization, whether the reorganization leads to an increase in the awareness, or whether a third independent variable is responsible for the two new conditions at that stage of development."

Dr. Hoffman went on to question the idea that imaginative play is particularly linked to femininity and to a forward movement in its development. "Does this ... imply that imaginative play and femininity are causally related to one another or is there an independent variable responsible for both of these states? Further, how can a psychoanalyst prove a normative statement that imaginative play is more connected with femininity than with masculinity? ... looking at the groups as a whole, are the activities in one gender ... more or less imaginative than in the other? When a little boy demonstrates his imagined power through his ball play or plays out or tells of activities fraught with dangers, is he being any less imaginative than a little girl who describes in details her imaginary interactions among family members"?

Dr. Hoffman then turned to the clinical material. He stressed the marital problems. "The major fact in Martha's life, when she presented herself at age 6 and throughout the treatment was the marital discord leading to the parents' separation." He recapitulated some of the highlights of the treatment, raising questions about certain conclusions. He questioned Dr. Fischer's observation that the game of catch was like the play of a toddler. Dr. Hoffman wondered if the game would be questioned in this way if either patient or analyst were male. "I wonder if her idea, that the ball playing was like the play of a toddler, reflects an attitude, perhaps transmitted unconsciously to the patient, that ball playing (ie a 'boyish' activity) is a symptomatic, even a regressive activity, activity that the two of them should try to understand, in order for Martha to move beyond, on her way to developing feminine identification."

Dr. Hoffman raised an alternative understanding of the movement of the treatment: essentially, that Martha was influenced by Dr. Fischer's attitude that femininity and "girlish things" were positive and progressive and that masculine activities and identifications needed to be suppressed. He examined the role of anger. While agreeing that being a girl was intertwined with vulnerability for Martha, he was not certain about the role of anger. "Did Martha have an idea that girls do not get angry? Or, was her idea that girls are vulnerable a defensive construction to deny dangerous power and anger which girls and women (like mommy) can have?" He suggested that Martha's increasingly being nicer to the analyst could be "a reaction formation on the way towards health or ... to undo frightening aggressive feelings and fantasies towards the analyst which could continue to operate outside her awareness. From my perspective I would ask whether, now that she is more girly, she has to mask or hide her anger"? He wondered if Dr. Fischer ever asked Martha if girls aren't supposed to get angry or how the anger of girls or mommies differs from that of boys or daddies.

"I say this because the focus of the work seems to lead to the conclusion (at least for Martha) that only 'boyish creatures' can be angry. Once the anger is less frightening and/or less intense, it is safe to be and act like a girl. ... once one acts and feels like a girl, ... soccer and action and wearing a baseball cap are activities that are given up." He later pointed out that Martha had referred to her sister getting her period and becoming moody with tantrums. Martha's associating this anger with menses with her own uncontrollable anger suggested to Dr. Hoffman support for his own "hypothesis that for Martha, aggression by women provoked more anxiety than aggression by men."

Dr. Hoffman asked if Martha might have become more girly to please her analyst. "Did Dr. Fischer help Martha find her 'true self,' the feminine side? Or, was some of the more 'girly' appearance a mask (or to some extent a 'false self')? He said that if "there was something about Martha's pretence to be a little boy that looked like a caricature of a boy to Dr. Fischer ... that ... would be a confirmation that the boyish phallic activity was a way to defend against her feminine feelings."

In his conclusion, Dr. Hoffman came back to two of Dr. Fischer's conclusions--that "genital sensations lead to a particular kind of play in little girls" and that "little girls have more imaginative play than little boys."

"As psychoanalysts collaborate with both neuroscientists and social scientists, we can try to integrate the findings from the various disciplines. Why little girls are one way and little boys another way is certainly a result of many varied complex interactions. I think it is too much of an inferential leap to draw conclusions about causality from psychoanalytic data. A good psychoanalyst, like Dr. Fischer, attempts to understand the patient's inner experience, particularly the sources of conflict and unpleasant affects. Transmitting this understanding to the patient can help a patient, like Martha, better master her anxieties and develop more effective adaptive mechanisms. Martha told Dr. Fischer when they first met that 'neither mommy nor daddy understood her.' Dr. Fischer demonstrated to Martha and to us, how well she did."

Discussion from the Floor

Dr. Noah Shaw said that Dr. Fischer's presentation explicates two things that go on in child analysis: 1. defense analysis and 2. one criterion for successful analysis is when development gets back on track. He said that we can see how she was able to help Martha achieve that.

Dr. Jack Pelaccio liked Dr. Fischer's inferential leaps. He called it a femininely elegant analysis. This girl was not dissatisfied with her genitals. Dr. Fisher went in the direction of analyzing Martha's anger and helped Martha identify with her. Dr. Fisher offered her this model of femininity which Martha was able to achieve when she became free of worries manifested by her phallic defensiveness.

Dr. Arlene Kramer Richards found it interesting that Dr. Fischer used herself. Martha might have had lots of feelings about her mother not being a good female model--but she had Dr. Fischer. She said that to rely on inner genital sensations as leading to femininity isn't supported by data. There are girls born without vaginas. It's not simply imagining unseen internal genitalia. It's also an external genital. She said that it's a very complicated thing being a girl. "It's not the whole story; 'you're a girl if you have a vagina and you're not if you don't.'"

Dr. Martin Silverman was struck by the defensive quality of the aggression this little girl showed. He referred to the intense aggressiveness which defended against her femininity.

Dr. Charles Sarnoff said that he recognized some things in this case from his own practice. This is a young lady who had problem with her symbolizing function. Her symbols were "affect porous" As a result, she defensively turned to aggression, regression to anal-sadistic behavior. This appears in Freud's first description of latency. He said that Dr.Fischer then involved her in obsessive compulsive defenses. "You helped the child strengthen the rituals, the back and forth play?With latency you have the attempt to deal with drives through symbols. If that fails, you have anal sadistic defense." Referring to a statement of Dr. Fischer that there is a change in perception of self with menarche, he asked Dr. Fischer what she had seen in this regard. Did she come out of problems of latency as she moved into menarchy"

Dr. Fischer's Response

Dr. Fischer responded to Dr. Hoffman that he had brought up many interesting points. She started from the beginning with his wondering whether we can talk about causality between genital sensation and psychic reorganization. "I'm extending that idea from the understanding that oral, anal and phallic sensation lead to psychic reorganization and I'm saying that genital sensation leads to psychic reorganization in the same way."

Dr. Fischer said that Martha's gender identity was clearly female. She was a girl but not a girly girl. She took umbrage at the idea that she wouldn't understand the ball throwing. Martha did both kinds of ball play, but the push into the environment--this was a very different kind of play. She said that Dr. Hoffman's question about anger and femininity is a good one, but she did not think she conceptualized the idea that females can't be angry. Martha was quite angry. It was more that it interfered with her developmental progress. It kept her from integrating her girly self. Dr. Hoffman's point about imaginative play was a good one. It's true that both boys and girls play imaginatively but boys' play is more action-oriented. Girls' play turns more symbolic. This is where Martha faltered. Identification with father is important in any girl's development and it played a very important role in hers. Dr. Fischer did not think that Martha was being compliant with her. She was more obstructionistic than compliant. She also stressed that for the sleep-over Martha pulls out the animal, but it's not the animal that's significant. It's the blankie ribbon she puts her finger in. That seems like a nice integration of her genitals. In response to Dr. Sarnoff, Dr. Fischer said that she did not see Martha into Menarche.